This subproject is one of many research subprojects utilizing the resources provided by a Center grant funded by NIH/NCRR. The subproject and investigator (PI) may have received primary funding from another NIH source, and thus could be represented in other CRISP entries. The institution listed is for the Center, which is not necessarily the institution for the investigator. To evaluate the effect of the following 2 interventions on time to attainment of independent oral feeding in preterm infants born <30 weeks gestation: 1. Efficacy of a swallowing exercise 2. Efficacy of the prone position during oral feeding It is well recognized that preterm infants have difficulty transitioning from tube to oral feeding (bottle/breast), particularly those born <30 weeks gestation (6). Such difficulty frequently leads to prolonged hospitalization, delayed mother-infant reunion and increased medical cost. Poor oral feeding may result from immature oral-motor skills, disorganized or delayed swallowing, and/or in-coordination of sucking, swallowing, and respiration. The latter is essential if these infants are to feed safely, i.e., with no aspiration, and successfully, i.e., capable of finishing all their feedings by mouth with adequate daily weight gain. There is no understanding of when and how such coordination develops. Clinical signs of in-coordination typically include oxygen desaturation, episodes of apnea and bradycardia during feeding, and/or coughing/choking. We have recently developed a nipple device that allows for the simultaneous monitoring of sucking, swallowing, and breathing (3-6). With this tool, we have gained an understanding of the development of sucking in infants and established a 5-stage scale that assesses the level of infant sucking skills (4). From our studies, we have noted that non-nutritive sucking, e.g., on a pacifier, matures before nutritive sucking (3). Insofar as swallowing is minimal during non-nutritive as compared to nutritive sucking, we speculate that sucking skills mature before sucking, swallowing, and breathing are coordinated. The maturation of the swallowing process in preterm infants is not well understood. Oral feeding difficulties resulting from disorganized and delayed swallow usually are diagnosed by videofluoroscopy. Knowledge of pulmonary maturation in preterm infants has progressed significantly over the last decade as reflected by the increased survival of the preterm population. However, the adaptability of the respiratory system to regular interruption of airflow resulting from swallowing events during oral feeding is unclear. Infants are primarily abdominal breathers as a result of the immaturity of the rib cage effectors that restrict the mobility of the upper chest (1). It is uncertain to what extent such limitation may impair the swallow-breathe process during oral feeding when swallowing frequency is increased as it is the case during oral feeding. When bottle feeding, infants are held usually in a relatively supine position similar to that used when they are breastfeeding. However, infants with anatomical oral anomalies, e.g., Pierre Robin syndrome, or conditions such as meningocele have benefited from being fed in a prone position. In general, this approach has facilitated their respiration during oral feeding (8). Similar benefits have been observed when prone feeding was used for sick preterm and fullterm infants (7). Given that preterm infants <30 weeks gestation, during their prolonged hospitalization, receive minimal stimulation appropriate for the development of their immature anatomical structures and physiological functions, we hypothesize that interventions can be developed to compensate for such void. Inasmuch as oral feeding difficulty can arise from sucking, swallowing, and/or respiration, the present protocol will evaluate 2 interventions aimed at ameliorating swallowing, and the interaction of swallow-breathe during oral feeding. Interventions to improve sucking are being investigated under our protocol H# 7469/GCRC #523.